Royal College of General Practitioners conference, Edinburgh, October 2007 Weight management solutions in practice Paula Hunt Registered Dietitian on behalf of Weight Watchers Adults with healthy BMI now in minority (prevalence figures shown below are approximate) ~10% prevalence Underweight BMI under 18.5 ~25% prevalence Healthy weight BMI 18.5 to 24.9 ~40% prevalence Overweight BMI 25 to 29.9 ~25% prevalence Obese BMI 30 plus The health implications? 1.life-threatening diseases (CHD, Ca) 2.risk factors (raised BP, cholesterol, diabetes) 3.pain and unhappiness 4.disruption/irritation and embarrassment A role for primary health care? Yes but……….. they report feeling overwhelmed and ineffective Campbell, 2000, Harvey et al, 2001 the present system appears to offer no real incentives Dr Foster, 2003 to achieve ‘gold standard’ interventions significant up-skilling and support is required Moore et al, 2003, Laws et al, 2004 What health professionals need most More resource: more time more support from others ‘new layer’ of health service to work with, in partnership More joined up working between acute services, social services, community services, charities and slimming organisations Poulter, Hunt and Scott, 2003 Internal report for Weight Watchers What are the treatment options? Lifestyle change - healthy eating - physical activity - behavioural support Anti-obesity drugs Obesity surgery Behavioural element is key Ongoing behavioural support is associated with better success Finnish Diabetes Prevention Programme (Tuomilheto et al, 2001) Diabetes Prevention Programme (DPP Research Group, 2002) Management of obesity and overweight: an analysis of reviews (Health Development Agency, 2003) What would success look like? Ideal target weights are no longer recommended. They are unrealistic and unachievable. (Maryon Davis 2000, National Heart Forum 2007) For health benefits, 5-10% weight loss is significant and this is achievable for most people significant. (Royal College of Physicians 2003, NICE 2006) Proportion of patients losing ≥ 5% Nature of support with weight loss Nurse led, primary care Counterweight,1 yr (Laws, Eu J Cl Nutr, 2005) Completers only analysis Intention to treat analysis 33% (49% completed) 16% Physician/dietitian led, at 1 yr (Ashley, Arch Intern Med, 2001) 53% (65% completed) 34% 38% Weight Watchers, 1 yr (Heshka, JAMA, 2003) 47% (77% completed) Weight Watchers, 2 yrs (Heshka, JAMA, 2003) 54% (73% completed) 34% How much does it cost? Cost (£) per QALY Lifestyle Dietary change with dietitian Weight Watchers group Behavioural with psychologist Exercise with a physiotherapist £ 174 £ 1,012 £ 4,360 £ 9,971 Anti-obesity medication Sibrutamine (Reductil) £3,200 to £16,700 Orlistat (Xenical) £24,431 Bariatric surgery Gastric bypass Gastric band £6,289 £8,527 Data from: NICE, 2006, Trueman and Flack, NICE conference, 2006 NICE Guidance on Obesity 1. 2. (December 2006) Patient choice Non-NHS services should complement, not replace Quality and standards “…commercial and self-help programmes for weight loss must meet best practice guidance.” 3. NICE Guidance on Obesity (December 2006) realistic healthy target weight (usually 5 to 10%) aiming for a maximum weekly weight loss of 0.5 to 1 kg focusing on long term lifestyle changes addressing both diet and activity, and offering a variety of approaches using a balanced, healthy-eating approach offering practical, safe advice about being more active including some behaviour-change techniques recommending and/or providing ongoing support Evidence for success – 2 year RCT Percentage losing at least 5% of their starting weight Weight Watchers (n=150) Comparison group (n=159) (2 dietitian appointments plus self help materials) at 1 year at 2 years 38% 34% Heshka et al 2003, JAMA, 289:14:1792-8 20% 21% Percentage losing at least 10% of their starting weight Weight Watchers (n=150) Comparison group (n=159) (2 dietitian appointments plus self help materials) at 1 year at 2 years 21% 16% Heshka et al 2003, JAMA, 289:14:1792-8 9% 6% Lifetime Member Study (2003): Comparison commercial group weight loss results relative to past clinical trials WW % regain in relation to clinical trials outcomes % of weight loss regained 100 80 60 40 20 0 1 2 Time of follow-up (year) 5 WW Clinical trials Lowe M et al 2004, Int J Ob 28 (supp 11: S29) Referral Scheme Attendance at 12 Weight Watchers meetings with support of highly trained leader For £35 Feedback to PCT about patients progress Effective communication and support to PCTs, referring health professionals and patients Groups held in ‘hard-to-reach’ communities Referral Scheme - first year results Total sample (n=198) Weight gain halted in 92% of patients Mean BMI decreased from 37.1 – 35.4 Mean weight loss – 4.3 kg Average 4.2% loss of initial weight 39% losing 5% or more at 12 weeks (Hunt and Poulter, Practice Nursing, 2007) Comparison regular attendances Weight Watchers Referral Scheme - first year results (July 2006) Regular (n=106) Irregular (n=92) Mean weight loss (kg) Reduction in BMI Attendance % losing 5% or more % losing 10% or more 5.7 37.0 2.6 36.9 34.9 36.1 12 weeks 62 (n=61) 14 (n=15) Less than 12 weeks (average 5 weeks) 16 (n=15) 4 (n=4) Hunt and Poulter, Practice Nursing 2007 NHS Ayrshire & Arran - referral to Weight Watchers “To be honest my weight has never really bothered me over the years. Now I know how much difference it makes being lighter I’m wondering why I didn’t do it years ago. I can move around so much more freely and the pain has gone. I have heaps of energy. I don’t need the second knee done any more. You could say that my losing weight has saved the NHS a fortune! Someone told me a knee replacement costs £10,000.” Molly, Patient, Ayrshire Anglesey Health Board “I’d been watching my weight for years. I was eating the right foods – just too much of it. When the nurse suggested I try Weight Watchers, I said I’d have a go but I didn’t think for a moment that I’d lose 2 stone. Now I realise it’s more than just following a diet. Attending the Weight Watchers meeting with a decent crowd and a really good leader makes so much difference” Elisa, Patient, Isle of Anglesey Summary 1. Referral to a third party provider which meets NICE quality standards can be a cost-effective solution. It enhances the range of weight loss services health professionals can offer thereby simultaneously widening patient choice and reducing the burden on health professionals. There is policy support for this approach. 2. 3.